Managing IBD medication in the long term

Managing IBD medication in the long term

In patients with chronic conditions such as Crohn’s Disease and Ulcerative Colitis, managing medications is like a delicate balancing act. It’s important to consider both the risks and rewards. These include the risks of medications such as infections and other side effects, and risks of not treating (or undertreating) the disease, such as worsening disease activity, cancer, need for surgery and pregnancy issues. This is compared to the rewards of the medication, such as better disease control and pregnancy outcomes, and avoidance of surgery and hospitalization and the rewards of stopping medications such as convivence and medication costs. Unfortunately there’s no simple one-size-fits-all approach.

In patients with chronic conditions such as Crohn’s Disease and Ulcerative Colitis, managing medications is like a delicate balancing act. It’s important to consider both the risks and rewards. These include the risks of medications such as infections and other side effects, and risks of not treating (or undertreating) the disease, such as worsening disease activity, cancer, need for surgery and pregnancy issues. This is compared to the rewards of the medication, such as better disease control and pregnancy outcomes, and avoidance of surgery and hospitalization and the rewards of stopping medications such as convivence and medication costs. Unfortunately there’s no simple one-size-fits-all approach.

Treatment pyramid for Crohn’s and Colitis

In Australia, the step-up therapy is used due to Medicare PBS restrictions. In comparison to other countries where they would start with biologics and work backwards.

The preference is to use the rapid step-up approach, which meets Medicare requirements but also helps for patients with severe disease. Using the rapid step-up approach reduces the likelihood of patients needing surgery or being admitted to hospital.

The evidence for the effectiveness of newer biologic therapy is better than older style medications. It is also found to be safer as well.

Choosing the right treatment

Before starting treatment, your gastroenterologist will consider the following:

  • Whether you have Crohn’s Disease or Ulcerative Colitis.
  • Where your disease is located.
  • The severity of your disease.
  • Whether you have other problems outside of your bowel, such as arthritis or rashes.
  • Your age.
  • Whether you plan to conceive in the future.
  • Your smoking status.
  • Other medical conditions you may have, such as cancer (past or present), risk of infection or heart failure.

The best medication or treatment plan is going to be different for every patient. But it needs to be the most effective for your disease, easy to take, least amount of side-effects, lowest possible cost for you and safe in pregnancy (if required).

What are the treatment goals?

First and foremost the aim is to make you feel better. This can include:

  • Stopping diarrhoea and/or rectal bleeding.
  • Stopping/Improving abdominal pain.
  • Stopping/Improving fatigue and/or joint pain.
  • Helping you get back to work, school or university.
  • Achieving your pregnancy goals.

The goals for your gastroenterologist might be slightly different, such as:

  • Heal the bowel (normal colonoscopy, MRI, faecal calprotectin).
  • Reduce the chance of needing surgery/hospitalisation.
  • Reduce the long-term risk of cancer associated with long-term uncontrolled inflammation.
  • Improve pregnancy outcomes.

Clinical scenario of a patient with Ulcerative Colitis

A patient presents with 6 months of diarrhoea, rectal bleeding and fatigue. The colonoscopy shows moderately severe colitis that extends through the entire colon.

The doctor starts them on a weaning course of prednisolone and mesalazine, and after 3 months they feels better but still not back to normal (faecal calprotectin should be under 100, but is still at 600).

They then commence Azathioprine, and 4 months later again are slightly better, but still not back to normal (with a faecal calprotectin of 400).

A repeat colonoscopy shows a slight improvement but there is still inflammation.

The doctor commences biologic therapy, and 3 months later the patient feels much better with no more diarrhoea or bleeding and energy levels have improved.

At 12 months the colonoscopy shows no evidence of residual inflammation.

The patient may think they are ‘cured’ and can stop taking all medication. However, it’s not as simple as this.

Their mesalazine, azathioprine and biologic mean they need to take 5 tablets daily and attend an infusion once every 8 weeks. This is also at a cost of $90 per month.

While the mesalazine is safe, it didn’t make much of a difference. And azathioprine did a little bit but has longer-term side-effects.

Therefore, the doctor advises to keep going with the biologic but reduce the dose of azathioprine. This is because biologics have the best evidence in disease that is proving refractory to simpler therapy and are safe in the long term.

The azathioprine helps reduce the risk of side-effects and maintain response to biologics, which can lose effect over time.

Loss of response to biologics

Biologic medications are made up of antibodies, which the immune system is designed to neutralise. This is because they are foreign particles that shouldn’t be there. The immune system produces antibodies to fight these off (aka anti-drug antibodies), which can stop the medication from working. This is worse in some medications (such as Infliximab) than it is in others.

Loss of response to biologics is 3 times highest in the first year. It is highest in male patients, those with more severe disease and those taking intermittent biologic therapy. One thing that can reduce the risk is azathioprine and/or methotrexate.

What to look at when stopping treatment

Before stopping treatment, the gastroenterologist will look at a number of factors:

  • How bad is the disease?
  • How long have you had it for?
  • Have we been able to achieve long-lasting remission?
  • Have you had a colonoscopy/MRI that is completely normal and remained normal for some time?
  • Do you plan to get pregnant?
  • Do you smoke?
  • Have you needed surgery?
  • Have you failed other medications?

A relapse is possible following treatment cessation when there is:

  • Ongoing disease activity despite clinical remission.
  • Past need for surgery.
  • Complex perianal disease.
  • Low adherence to azathioprine/methotrexate.
  • Past treatment failures.
  • Active smoking.

Successful treatment cessation general occurs when there is:

  • Presence of mucosal healing (no active disease at colonoscopy).
  • Normal calprotectin levels.
  • A milder disease course.

It is important to conduct a colonscopy and/or MRI before stopping medications, and again 6-12 months after stopping. A faecal calprotectin or intestinal ultrasound every 6 months will ensure things are going as planned, but if there is concern about the disease coming back medication will be re-started ASAP.

The right medication is different for everyone, but will be the safest medication that controls your disease.

Our gastroenterologists are well trained in the latest medications for both Crohn’s Disease and Ulcerative Colitis; make an appointment to see one today.

 

Contributed by Dr Paul Spizzo and Dr Alex Barnes